Provider Demographics
NPI:1013068642
Name:RENAISSANCE SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:RENAISSANCE SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:BOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-567-0269
Mailing Address - Street 1:2365 E FIR AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8016
Mailing Address - Country:US
Mailing Address - Phone:559-797-9100
Mailing Address - Fax:559-797-9103
Practice Address - Street 1:2365 E FIR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8016
Practice Address - Country:US
Practice Address - Phone:559-797-9100
Practice Address - Fax:559-797-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000544261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06569ZMedicare PIN